People who are immunocompromised have an increased risk of morbidity and mortality from many vaccine-preventable diseases.

A person can be immunocompromised as a result of:

congenital or acquired disorders

disease

immunosuppressive medical treatment

All people who are immunocompromised, or people who may be immunocompromised in the future as a result of disease or treatment, need to have a thorough risk assessment to determine their level of immunocompromise.

People who are immunocompromised need their vaccination history assessed carefully and a plan for future vaccination made. Live vaccines may be contraindicated in these people, or the person may need extra doses of inactivated vaccines to protect against disease.

Assessing the extent of immunocompromise

Vaccinating people who are immunocompromised can be challenging. It can be difficult to determine the extent to which a person is immunocompromised, because it depends on the underlying disease, medical treatment and other factors. The person may have:

mechanism, and duration of the effect on the immune system, of the medicine or other treatment

consequence of using combination therapies — for example, corticosteroids and other immunosuppressive therapies such as DMARDs (disease-modifying anti-rheumatic drugs), which can contribute to the nature, extent and length of the immunocompromising condition

anticipated duration of the person’s immunocompromised state, whether due to the therapy or the underlying disease

If there is uncertainty about how severely a person is immunocompromised and whether it is safe for them to receive a vaccine, do not vaccinate them. Seek expert advice from their treating physician or an immunisation specialist.

Assessing the need for extra vaccine doses

People who are immunocompromised may need extra doses of inactivated vaccines to optimise protection against specific diseases. An example is extra doses of pneumococcal vaccines for people with haematological malignancy.

To determine the need for additional doses, it may be useful to measure post-vaccination antibody titres in some circumstances, such as for adults or children who have received haematopoietic stem cell transplants (see Haematopoietic stem cell transplant recipients).

However, the risk of vaccine-related disease varies by vaccine and by individual.

It is important to carefully review people who are potentially immunocompromised for their suitability to receive a live vaccine.

Live vaccines are generally contraindicated for most people who are severely immunocompromised. If there is uncertainty about how severely a person is immunocompromised and whether it is safe for them to receive a vaccine, do not vaccinate them. Seek expert advice from their treating physician or an immunisation specialist.

People who are severely immunocompromised

People who are severely immunocompromised should not receive live viral or live bacterial vaccines.

People on immunosuppressive therapy

Live viral vaccines are contraindicated in people taking highly immunosuppressive therapy, including bDMARDs or tsDMARDs, or high-dose corticosteroids.

If there is any uncertainty about how severe the person’s immunocompromising condition is and whether they can safely receive live attenuated vaccines, do not vaccinate. Seek expert advice from their treating physician or an immunisation specialist.

People who may be only mildly immunocompromised include those who are receiving selected csDMARDs (conventional synthetic DMARDs) in low doses, either on their own or in combination with low-dose corticosteroids (<20 mg per day of prednisone-equivalent dose). These people can receive some live vaccines (for example, zoster vaccine) on advice from a specialist and after a risk assessment.

People who are immunocompetent but expect a change to their immunity because of their existing illness may be able to receive MMR- and varicella-zoster virus–containing vaccines on a case-by-case basis on advice from a specialist and after a risk assessment.

People receiving corticosteroid therapy

Table. Recommended timing of live vaccine doses in adults and children taking corticosteroids shows the recommendations for when patients on corticosteroids can receive live vaccines, depending on the dose and duration of therapy. There are several different formulations of systemic corticosteroids (for example, prednisone, dexamethasone, cortisone, methylprednisolone) — the table refers to a prednisone-equivalent dose. Convert systemic doses of different formulations of systemic corticosteroids (such as dexamethasone, cortisone and methylprednisolone) to a prednisone-equivalent dose to assess a person’s suitability to receive live viral vaccines.

Live attenuated vaccines (such as MMR, MMRV [measles-mumps-rubella-varicella], zoster, varicella and yellow fever) may be unsafe in people receiving corticosteroid therapy. The dose and duration of therapy with corticosteroids, and use of corticosteroids in combination with other immunosuppressive therapies such as bDMARDs and tsDMARDs, determine the effects on the immune system (see People with autoimmune diseases and other chronic conditions).

Another exception is zoster vaccine, which can be given to people ≥50 years of age taking low-dose corticosteroids (<20 mg per day of prednisone-equivalent dose), either alone or in combination with certain csDMARDs in low doses. At these doses, it is likely that the level of immunocompromise is not severe. Only vaccinate the person if a risk assessment indicates that it is safe.

Once treatment with corticosteroids has ended, assess whether the person has other underlying immunocompromising disease or is receiving other immunosuppressive therapy that may influence whether they can receive vaccines, particularly live vaccines.

Table. Recommended timing of live vaccine doses in adults and children taking corticosteroids

This table assumes that the person has no other factors that contribute to their being immunocompromised (such as an underlying medical condition or use of other immunosuppressive medicines).

Vaccine recipient

Prednisone-equivalent dose

Duration of therapy

Potential timing of vaccination

Adolescents aged ≥16 years and adults

<20 mg per day

Any duration

Any time during therapy

≥20 mg per day

<14 days

Immunise 1 month before starting corticosteroids or any time after stopping corticosteroids.

Immunise 1 month before starting corticosteroids or at least 1 month after stopping corticosteroids. Alternatively, the person may be able to receive live vaccines at any time during therapy, but only after seeking expert advice.

≥2 mg/kg per day

<14 days

Immunise 1 month before starting corticosteroids or any time after stopping corticosteroids.

Immunise 1 month before starting corticosteroids or at least 1 month after stopping corticosteroids. Alternatively, the person may be able to receive live vaccines at any time during therapy, but only after seeking expert advice.

≥20 mg per day

<14 days

Immunise 1 month before starting corticosteroids or any time after stopping corticosteroids.

Use of specific live vaccines in people who are immunocompromised

This section summarises information on the use of specific live vaccines in people who are immunocompromised. See also relevant disease-specific chapters for more details.

BCG vaccine (tuberculosis)

BCG vaccine is always contraindicated in people who are immunocompromised (see Tuberculosis).

Japanese encephalitis vaccine

People who are immunocompromised and need a Japanese encephalitis vaccine should not receive the live attenuated recombinant vaccine (Imojev). Use the inactivated vaccine (JEspect) instead (see Japanese encephalitis).

MMR vaccines

MMR-containing vaccines are contraindicated in people who are significantly immunocompromised as a result of a medical condition.

MMR-containing vaccines are contraindicated in people receiving high-dose systemic immunosuppressive therapy, such as chemotherapy, radiation therapy or oral corticosteroids.

Children and adults with HIV who are asymptomatic and have an adequate age-specific CD4+ count may receive MMR-containing vaccines. See Measles, Mumps and Rubella.

Oral typhoid vaccine

Rotavirus vaccine

Infants with severe combined immunodeficiency (SCID) should not receive rotavirus vaccine. They are unlikely to generate a protective immune response to vaccination and may have an adverse event following the vaccination.

Infants with HIV who are asymptomatic and have an adequate age-specific CD4+ count may receive rotavirus vaccine.

Yellow fever vaccine

Yellow fever vaccine is generally contraindicated in travellers who are immunocompromised and going to yellow fever–endemic countries.

However, certain travellers may receive the vaccine on a case-by-case basis after seeking specialist advice and having a risk assessment. This includes certain people with HIV (see Yellow fever).

People who have had a haematopoietic stem cell transplant after a dose of yellow fever vaccine are recommended to receive an extra vaccine dose if they will be in an area with a risk of yellow fever virus transmission. This is regardless of when they received their last yellow fever vaccine.

Varicella and zoster vaccines

Varicella-containing vaccines are contraindicated in people who are significantly immunocompromised as a result of a medical condition.

Varicella-containing vaccines are contraindicated in people receiving high-dose systemic immunosuppressive therapy such as chemotherapy, radiation therapy or oral corticosteroids. Carefully consider vaccination for people who are taking combinations of immunosuppressive therapies.

People with a current or recent severe immunocompromising condition, from a primary or acquired medical condition or treatment, should not receive zoster vaccine.

People who are anticipating being significantly immunocompromised in the future should seek specialist advice before receiving zoster vaccine.

People ≥50 years of age with mild immunocompromising conditions may receive zoster vaccine.

Adults with asymptomatic HIV may receive zoster vaccine on a case-by-case basis.

Inadvertently giving a live vaccine to someone who is immunocompromised

Promptly assess people who are immunocompromised and have been inadvertently given a live vaccine. Establish how severely they are immunocompromised and the level of risk for vaccine-associated adverse effects. This will inform appropriate management.

Management may include quickly giving immunoglobulin, or antiviral or antibacterial therapy, depending on the vaccine and clinical context.

Influenza vaccine

All people ≥6 months of age who are immunocompromised are recommended to receive an influenza vaccine every year (see Influenza).

Every year, new influenza vaccine strains can circulate in the community. Cross-protective immunity to these strains in the population is low. This underpins the need for annual seasonal influenza vaccination in all people, but particularly people who are immunocompromised.

If a major shift in the circulating influenza virus occurs, such as during an influenza pandemic, people who are immunocompromised might benefit from receiving 2 doses of inactivated influenza vaccine, at least 4 weeks apart, for an optimal immune response. This is regardless of their previous influenza vaccination history.

For example, during the 2009–10 H1N1 global influenza pandemic, adolescents and adults who were immunocompromised and who received 2 vaccines doses had better rates of seroconversion.6

Information about extra doses in people who are immunocompromised will be provided as necessary in these situations. Updated influenza vaccine recommendations are published every year on the Australian Government Department of Health website and updated in this Handbook.

There are precautions relating to the use of influenza vaccine in cancer patients who are neutropenic or receiving treatment with checkpoint inhibitors. See People with Cancer and Influenza.

Pneumococcal vaccine

People who are immunocompromised are recommended to receive extra pneumococcal vaccine doses in addition to the doses recommended for healthy people. The timing, number of doses and type of vaccine(s) depend on the person’s age, when the condition was diagnosed, whether they have already received pneumococcal vaccines and whether they are Aboriginal or Torres Strait Islander. See Pneumococcal disease and Catch-up vaccination.

Meningococcal vaccine

Certain people who are immunocompromised (particularly those with asplenia) may need extra doses of meningococcal vaccines. This applies to both MenACWY (quadrivalent meningococcal) and MenB (meningococcal B) vaccines. See Meningococcal disease.

HPV vaccine

People who have certain immunocompromising conditions are recommended to receive HPV (human papillomavirus) vaccine in a 3-dose course, regardless of their age at vaccination. See Human papillomavirus.

Household contacts and other close contacts of people who are immunocompromised should be fully vaccinated according to current recommendations. Their vaccination history should be reviewed, and they should receive any necessary catch-up doses. This helps protect people who are immunocompromised, whether they are a child or an adult, by reducing their exposure to disease.

Annual influenza vaccination is recommended for all household contacts (≥6 months of age) of people who are immunocompromised.

Household contacts of people who are immunocompromised may also need to receive additional vaccine doses, such as pertussis-containing vaccine and/or varicella vaccine (see Pertussis and Varicella).7-9

Live viral vaccines in household contacts

Vaccinating household contacts can reduce the risk of disease spreading to the person who is immunocompromised. Household contacts of people who are immunocompromised are recommended to be reviewed for their need to receive the following live attenuated viral vaccines:

MMR

MMRV

rotavirus

varicella

zoster (household contacts ≥50 years of age)

There is no risk of transmission of the MMR vaccine viruses, and an almost negligible risk of transmission of varicella-zoster vaccine virus (from varicella or zoster vaccine).

However, there is a small risk of transmission of the rotavirus vaccine virus. This can be minimised by handwashing and careful disposal of soiled nappies.

People with cancer, particularly generalised malignancy, are likely to be severely immunocompromised as a result of their disease and their treatment (such as chemotherapy or radiotherapy).

Guidelines for vaccination may vary by person, depending on their:

age

vaccination history

disease and treatment

level of immunocompromise

If a person has not completed a primary vaccination schedule before diagnosis and treatment, it is important to continue to offer routine or catch-up vaccination during their therapy, when possible, according to the principles in this section. Discuss any questions with the person’s treating oncologist and an immunisation specialist.

People with severe neutropenia

People with severe neutropenia (absolute neutrophil count <0.5 × 109 per L) should not receive any vaccines, to avoid an acute febrile episode.

People receiving immune-oncology therapy

People who are receiving cancer immuno-oncology therapies (checkpoint inhibitors) may have a higher risk of adverse events following immunisation with influenza vaccine.10,11

Checkpoint inhibitors include:

CTLA-4 inhibitors (such as ipilimumab)

PD-1 and PD-L1 inhibitors (such as nivolumab or pembrolizumab)

Live vaccines are not recommended for these patients. Caution is advised with inactivated vaccines, particularly the influenza vaccine. Consult the person’s treating oncologist about the risks and benefits of influenza vaccination in people taking these treatments.

Live vaccines for people with cancer

Live vaccines are contraindicated in cancer patients who are receiving immunosuppressive therapy and/or who have poorly controlled malignant disease.

Seronegative people, who are at risk of these diseases, are recommended to receive these vaccines at least 3 months after they finish chemotherapy, provided that the underlying malignancy is in remission and they are not severely immunocompromised.12

Inactivated vaccines for people with cancer

People receiving chemotherapy may receive inactivated vaccines (such as 13vPCV [13-valent pneumococcal conjugate vaccine] or hepatitis B) according to a routine or catch-up vaccination schedule. The immune response may be suboptimal, but it is safe for the person to receive these vaccines.

HPV vaccine

If the person needs HPV vaccine, 9vHPV (9-valent HPV) vaccine is recommended in a 3-dose schedule (0, 2, 6 months). This is regardless of the person’s age at the start of vaccination (see Human papillomavirus).

Influenza vaccine

Some people with cancer receive cancer immuno-oncology therapies, such as:

CTLA-4 inhibitors (such as ipilimumab)

PD-1 and PD-L1 inhibitors (such as nivolumab or pembrolizumab)

Consult the person’s treating oncologist about the optimal timing of influenza vaccination in people taking these treatments.

Cancer patients who have had a haematopoetic stem cell transplant or solid organ transplant and are receiving influenza vaccine for the 1st time after transplant are recommended to receive 2 vaccine doses at least 4 weeks apart (irrespective of age), and 1 dose each year after that. See Haematopoietic stem cell transplant recipients.

Pneumococcal vaccine

People with underlying haematological and other generalised malignancies are recommended to receive pneumococcal vaccine. This is because they have an increased risk of invasive pneumococcal disease.13

Children or adults who are newly diagnosed with cancer are recommended to receive 1 dose of 13vPCV (13-valent pneumococcal conjugate vaccine) and 2 doses of 23vPPV (23-valent pneumococcal polysaccharide vaccine). Children <5 years of age who are not up to date with age-appropriate doses (in the infant schedule) may need more doses. See Pneumococcal disease and Catch-up vaccination for details.

People who have completed cancer therapy

People who have finished cancer therapy and who completed a primary vaccination schedule before diagnosis can receive most of the following vaccines without having their antibody titres checked beforehand.

If the person is well and in remission for 6 months after therapy, they are recommended to receive the following booster doses after they have completed their primary vaccination schedule:

DTPa (diphtheria-tetanus-acellular pertussis)–containing and IPV (inactivated poliovirus)–containing vaccinesSingle dose of DTPa-IPV if <10 years of age. Single dose of either dT or reduced antigen content dTpa if ≥10 years of age, and a single dose of IPV.

MMR-containing vaccineSingle dose, followed by antibody testing for immunity to measles and rubella at 6–8 weeks after vaccination. People who have not seroconverted are recommended to receive an extra dose.

9vHPV vaccineSingle dose if >9 years of age and previously completed a primary course. If no previous doses received, a 2-dose schedule (0, 6–12 months) is recommended if commencing vaccination before the 15th birthday and no longer immunocompromised. A 3-dose schedule (0, 2, 6 months) is recommended if commencing vaccination from 15 years of age or if still immunocompromised. See Human papillomavirus.

Varicella vaccinePeople who are seronegative for varicella-zoster virus should receive a 2-dose schedule of varicella vaccine, at least 6 months after chemotherapy has finished. MMRV vaccine can be used in children aged <14 years. See Varicella.

Depending on the transplanted organ, people who have a solid organ transplant receive variable doses of immunosuppressive agents to prevent rejection. This may influence the effectiveness and safety of vaccines.

Where possible, children and adults having a solid organ tranplant should receive all routine scheduled or catch-up vaccines well before transplantation. It is important to administer all necessary live vaccines at least 1 month before solid organ transplantation, where possible.

Live vaccines are contraindicated in most post-transplantation protocols because of concerns about disseminated infection. However, data for transplant recipients are limited.18-20

Inactivated vaccines can be safely given after transplantation, but it is usually best to receive them at least 6 months after transplantation to maximise the immune response.18,21

Table. Recommended vaccines for people before and after a solid organ transplant

The recommendations in this table are built on the principle that, where possible, children and adults should complete an age-appropriate vaccination schedule for all vaccines before transplantation. If this has not occurred, the person should receive additional vaccine doses before transplantation, if possible. Some additional vaccine doses are also recommended after transplantation (see ‘Comments’ column).

Vaccine

Before transplantation

After transplantation, (if full vaccine course not given beforehand)

Comments

DTPa (diphtheria-tetanus-pertussis)–containing vaccine for children <10 years of age and dTpa for those ≥10 years of age

Yes

Yes

Recipients <10 years of age and not previously vaccinated should receive at least 3 primary doses as DTPa-containing vaccine, and then follow the routine schedule for their age.

Recipients ≥10 years of age and not previously vaccinated should receive the 1st dose as dTpa, followed by 2 doses of dT. If dT is unavailable, complete vaccination course with dTpa.

Adults who have received at least 3 primary doses of a diphtheria-tetanus-pertussis–containing vaccine should receive a dose of dTpa after transplant if their last dose was more than 10 years ago.

Adults who have received a routine course of polio vaccination in childhood are recommended to receive a booster every 10 years if they plan to travel to a polio-endemic area or have an occupational risk of polio exposure (eg laboratory workers).

Influenza vaccine

Yes (1 dose every year for people ≥6 months of age)

Yes (2 doses in 1st year after transplant, then 1 dose every year after that)

2 doses in 1st year after transplant should be given 4 weeks apart.

Children aged 6 months to <9 years are recommended to receive 2 doses before transplant if they are receiving influenza vaccine for the 1st time.

MenB (meningococcal B) vaccine

Yes, if at risk due to age or other defined risk factors (see comments)

Yes, if at risk due to age or other defined risk factors (see comments)

MenB vaccine is recommended for certain age groups and individuals with specific risk factors placing them at increased risk of invasive meningococcal disease (see Meningococcal disease).

Autologous HSCT recipients often have impaired immunity due to high-dose chemotherapy and radiotherapy. GVHD is not a concern because the transplant recipient supplies the donor stem cells. In most cases, autologous HSCT recipients recover their immunity more quickly than allogeneic HSCT recipients.

Persisting immunocompromise is common, particularly in people with chronic GVHD after allogeneic HSCT. Chronic GVHD is associated with functional hyposplenism and, therefore, increased susceptibility to infections with encapsulated organisms, especially Streptococcus pneumoniae. People with chronic GVHD who remain on immunosuppressive medicine are also recommended to receive antibiotic prophylaxis.24

Published guidelines do not support separate vaccination schedules for autologous or allogeneic HSCT recipients because of limited data. The same vaccination schedule is recommended for both groups, regardless of the donor source (peripheral blood, bone marrow or umbilical cord) or preparative chemotherapy (ablative or reduced intensity).26,27 However, recommendations for receiving live vaccines may vary according to the person’s level of immunocompromise after HSCT.

Do not give live vaccines to HSCT recipients with ongoing GVHD or who remain on immunosuppressive therapy, regardless of the time since HSCT.

Inactivated vaccines in HSCT recipients

HSCT recipients usually have a poor immune response to inactivated vaccines during the first 6 months after HSCT.

Haematopoietic stem cells from donors who receive hepatitis B, tetanus, Hib and pneumococcal conjugate vaccines before stem cell harvesting can improve early antibody responses in HSCT recipients who receive vaccines during the post-transplantation period.28-31 However, practical and ethical considerations can limit the use of donor immunisation.

Table. Recommendations for revaccination after haematopoietic stem cell transplant in children and adults

These recommendations are regardless of previous vaccination history. Young children may need extra doses of certain vaccines in addition to those in this table. Young children should complete the recommended age-based vaccination schedule after completing the primary post-HSCT vaccination doses in this table. See the relevant disease-specific chapters in this Handbook for details.

Vaccine

6 months after HSCT

8 months after HSCT

12 months after HSCT

24 months after HSCT

Comments

DTPa (diphtheria-tetanus-pertussis)–containing vaccine for children <10 years of age and dTpa for those ≥10 years of age

Yes

Yes

Yes

Not needed

For recipients <10 years of age, give all 3 primary doses as DTPa-containing vaccine.

For recipients ≥10 years of age, give the 1st dose as dTpa, followed by 2 doses of dT. If dT is unavailable, complete vaccination course with dTpa.

Young children should complete the recommended age-based vaccination schedule after receiving the 3 primary post-HSCT vaccination doses.

If a high-dose formulation is not available, give single-strength hepatitis B vaccine in each arm at each dosing interval or give the standard vaccination course, then check hepatitis B surface antibody titres 4–8 weeks after the last vaccine dose. If titres are <10 mIU/mL, repeat the vaccination course.

9vHPV (9-valent human papillomavirus vaccine

No

Yes

Yes

(see comments)

Yes

(see comments)

A 3-dose schedule (0, 2, 6 months) of 9vHPV is recommended.

Specific immunogenicity data for HSCT recipients are not available. Better immune responses are obtained at >12 months after transplant, when the person’s immune system is better reconstituted.

For people >19 years of age, conduct a risk assessment to determine their need for vaccination (see Human papillomavirus).

IPV (inactivated poliovirus) vaccine

Yes

Yes

Yes

Not needed

A 3-dose course of IPV vaccine is recommended. This can be given as DTPa-IPV or dTpa-IPV ( see ‘DTPa’ above).

Influenza vaccine

Yes (2 doses in 1st year after transplant, then 1 dose every year after that)

People who have finished immunosuppressive therapy, have no chronic graft-versus-host-disease and have reconstituted cell-mediated immunity can receive MMR vaccine.

Check serology 4–6 weeks after 1st vaccine dose. If there is no seroconversion, repeat the dose.

Alternatively, 2 doses can be given. This approach is preferable for young children. If possible, check serology 4–6 weeks after 2nd dose to confirm seroconversion. Seek specialist advice if no seroconversion after 2nd dose.

Children who acquired HIV around the time of their birth are substantially different from adults with HIV. Young children’s immunisation and first exposure to vaccine antigens occur after HIV is acquired. In adults with HIV, most vaccines induce a secondary (boosted) immune response that builds on a previous immune response.

People with HIV of any age whose disease is well controlled are likely to respond well to vaccines. HIV is usually well controlled when:

the person is on combination antiretroviral therapy

they have an undetectable or low viral load

they have a good CD4+ lymphocyte count

Table. Levels of immunocompromise in children and adults with HIV

Level of immunocompromise

Infant <12 months of age, CD4+ count per μL (CD4+ cells as % of total lymphocytes)

Child 1–5 years of age, CD4+ count per μL (CD4+ cells as % of total lymphocytes)

Child ≥6 years of age or adult, CD4+ count per μL (CD4+ cells as % of total lymphocytes)

Not immunocompromised

≥1500 (≥25%)

≥1000 (≥25%)

≥500 (≥25%)

Moderately immunocompromised

750–1499 (15–24%)

500–999 (15–24%)

200–499 (15–24%)

Severely immunocompromised

<750 (<15%)

<500 (<15%)

<200 (<15%)

Source: Wilfert et al38

Consider other factors such as concurrent medical conditions or medications when assessing levels of immunocompromise in children and adults with HIV. Please refer to the relevant section of this chapter.

Live attenuated vaccines for people with HIV

BCG vaccine

Children or adults with HIV should not receive BCG vaccine, because of the risk of disseminated BCG infection.39,40 See also Tuberculosis.

Japanese encephalitis vaccine

People with HIV who need Japanese encephalitis vaccine should not receive the live attenuated recombinant vaccine (Imojev). Use the inactivated vaccine (JEspect) instead (see Japanese encephalitis).

MMR vaccine

Children with HIV should receive MMR vaccine in a 2-dose schedule at 12 months and 18 months of age, unless the child has a CD4+ count of <750 per µL.41-43

Children with HIV are likely to have a better serological response after the 2nd dose of MMR vaccine.44,45 They can receive the 2nd dose soon after the 1st dose (with a minimum interval between doses of 4 weeks) to increase the likelihood of a serologic response to all 3 vaccine components. This is particularly recommended if the child is travelling overseas or if there is a local measles outbreak.

Measles may cause severe disease in children with HIV, particularly those with a CD4+ count of <750 per µL, who may have reduced protection from vaccination. Children with HIV should receive normal human immunoglobulin as post-exposure prophylaxis after being exposed to measles, regardless of vaccination status (see Measles).46

Asymptomatic adults with HIV should receive 1 or 2 doses of MMR vaccine if they have a CD4+ count ≥200 per µL and are seronegative for any of the vaccine components. The number of doses depends on the number of previous doses and whether they seroconvert. MMR vaccine does not have a significant effect on the CD4+ count or viral load of adults with HIV.47

People with HIV are not recommended to receive the combination MMRV vaccine. There are no data on MMRV vaccine in people with HIV (see Varicella).

Rotavirus vaccine

Infants with HIV who are asymptomatic can receive rotavirus vaccine according to the routine age-based schedule.

Rotavirus vaccines seem to be safe and immunogenic in infants with HIV, but data are limited.48,49

Infants with HIV who are severely immunocompromised should not receive rotavirus vaccine (see also Rotavirus).

Typhoid vaccine

People with HIV should not receive oral live attenuated typhoid vaccine. Use the inactivated parenteral Vi polysaccharide typhoid vaccine instead (see Typhoid fever).

Varicella vaccine

Asymptomatic adults and children ≥12 months old with HIV may receive the varicella vaccine.

Children ≥12 months of age with an age-specific CD4+ count of ≥15% of total lymphocytes are recommended to receive 2 doses of monovalent varicella vaccine at least 3 months apart.53,54

Adults with HIV who are varicella seronegative and have a CD4+ count of ≥200 per µL are recommended to receive 2 doses of monovalent varicella vaccine at least 3 months apart.54

People with HIV are not recommended to receive the combination MMRV vaccine. There are no data on MMRV in people with HIV (see Varicella).

Yellow fever vaccine

People with HIV who are not immunocompromised (CD4+ count of >200 per µL) can receive yellow fever vaccine if they are at risk of infection. People with HIV should only receive yellow fever vaccine if potential exposure to yellow fever virus is unavoidable.

Zoster vaccine

Adults with symptomatic HIV infection are not recommended to receive zoster vaccine.

People with asymptomatic HIV infection can receive zoster vaccine if they are on antiretroviral therapy, have a very low or undetectable viral load, and have a CD4+ count of ≥350 per µL.

Some experts suggest that adults with a CD4+ count of >200 per µL can safely receive zoster vaccine if there is a strong indication to vaccinate.56 Seek expert advice from the treating physician or an immunisation specialist. Confirm previous infection with varicella-zoster virus using serological testing before vaccination.

Zoster vaccine is only registered for use in adults ≥50 years of age. (See also Herpes zoster.)

Meningococcal vaccines

People with HIV may have a diminished immune response after a single dose of MenACWY.57-59 However, this improves for some serogroups after a 2nd dose.58-61

There are no clinical data on the use of MenB vaccine in people with HIV. Vaccination is recommended based on the expected benefit in these people.

HPV vaccine

Children (≥9 years of age) and adults with HIV can receive 9vHPV vaccine. HPV vaccines are safe and immunogenic in people with HIV.62-64

People with HIV are recommended to receive a 3-dose course of 9vHPV vaccine at 0, 2 and 6 months if they are either:

female aged 9–45 years, or

male aged 9–26 years

Males aged 27–45 years who receive HPV vaccine are unlikely to have different immunogenicity or adverse events compared with females in this age group, for whom the vaccine is currently registered. However, these men may have less benefit if they have already been infected with HPV. HPV vaccine provides the most benefit when given to children or young adolescents before sexual debut (see Human papillomavirus).

Assess the need for, and potential benefits of, vaccination in older adults before HPV vaccination (see Human papillomavirus). Discuss with the treating specialist and an immunisation expert, if required.

DTPa/dTpa, Hib and IPV vaccines

Hepatitis A vaccine

Hepatitis A vaccines are immunogenic in most children with HIV.66 Hepatitis A vaccine is only recommended for use in non-immune people with HIV if they have independent risk factors for acquiring hepatitis A (see Hepatitis A).

Hepatitis B vaccine

People with HIV can safely receive hepatitis B vaccine. Because of immune suppression, they may have a diminished immunological response. Check for previous hepatitis B infection using serological testing before vaccination.

Limited studies in HIV1-positive adults show an improved and accelerated serological response to a vaccination schedule that comprises 4 double doses. This means 2 injections of the standard adult dose (using Engerix-B) on each occasion, at 0, 1, 2 and 6 months.67,68

Children with HIV are recommended to receive 3 doses of hepatitis B vaccine using an adult formulation. This is double the standard recommended dose for children.53,54

Measure the antibody levels when the vaccination schedule is finished (1 month after the final vaccine dose). If the titre of antibody to hepatitis B surface antigen is <10 mIU per mL, give extra doses (see Hepatitis B).

Influenza vaccine

All adults and children (≥6 months of age) with HIV are recommended to receive influenza vaccine every year.

All children with HIV <9 years of age are recommended to receive 2 doses at least 4 weeks apart the 1st time they receive influenza vaccine. HIV viral load may increase after influenza vaccination, but the vaccine does not affect CD4+ counts, and the benefits exceed the risk.69-72 (See also Influenza.)

Children aged >12 months and adults who are newly diagnosed with HIV are recommended to receive a single dose of 13vPCV, followed by 2 doses of 23vPPV. If they have previously received doses of 23vPPV, they are recommended to receive the dose of 13vPCV 12 months after their last 23vPPV dose. If they have already received at least 2 doses of 23vPPV, no further 23vPPV doses are recommended. See Pneumococcal disease for age-specific recommendations.

Q fever vaccine

There are no data on Q fever vaccine in people with HIV. Q fever vaccine is contraindicated in people who are immunocompromised.

Typhoid, Japanese encephalitis and rabies vaccines

People with HIV can safely receive the following vaccines if they are travelling or living in an at-risk area:

People with an absent or dysfunctional spleen are at a lifelong increased risk of fulminant bacterial infection, especially invasive pneumococcal disease (IPD).13,74 In addition to being up to date with all routinely recommended vaccines, people with functional or anatomical asplenia are recommended to receive:

People having an elective splenectomy are recommended to receive all extra vaccine doses by 2 weeks before the scheduled operation date, if possible.

People having an unplanned splenectomy are recommended to start receiving extra vaccine doses from about 1 week after the splenectomy.76

Children with asplenia are also recommended to receive antibiotic prophylaxis to prevent bacterial infection, until they are at least 5 years of age.77,78

Vaccination cannot protect against all bacterial infections, or even all pneumococcal serotypes that cause IPD. This makes it important that people with asplenia know about the lifelong increased risk of severe bacterial infection, even if they have received all appropriate vaccinations.

Educate all people with asplenia, and their parents and carers, about the importance of recognising and treating febrile illnesses early. This includes using emergency antibiotics. Asplenic people are recommended to wear a medical alert.

Table. Recommendations for vaccination in people with functional or anatomical asplenia

Infants can receive MenB vaccine from 6 weeks of age to align with the schedule for other routine infant vaccines. People who are at increased risk of meningococcal disease can receive MenB and MenACWY vaccines together. (See also Meningococcal disease.)

Pneumococcal vaccines

≤12 months

Give a 3-dose primary course of 13vPCV, with a 4th dose of 13vPCV at age 12 months.

Give a single dose of 23vPPV at age 4 years and another dose of 23vPPV, at least 5 years later.

The above doses of 13vPCV should be followed with two doses of 23vPPV. The first dose of 23vPPV should be given 12 months after the last 13vPCV dose or at 4 years of age, whichever is later. The second dose of 23vPPV should be given 5 years after the previous 23vPPV dose.

≥5 years

If the condition is newly diagnosed or the person has never received a dose of 13vPCV due to the presence of the risk condition, give a single dose of 13vPCV, followed by 2 doses of 23vPPV (as below).

The recommended interval between a 13vPCV dose and a subsequent 23vPPV dose is 12 months (an interval of 2–12 months acceptable). The recommended minimum interval between any two 23vPPV doses is 5 years.

There is a maximum limit of 2 doses of 23vPPV. Therefore, if the person has already received at least 2 doses of 23vPPV, no further 23vPPV doses are required.

If the person has received 1 dose of 23vPPV previously, give the 13vPCV at least 12 months after the previous 23vPPV dose. Give the 2nd 23vPPV dose 12 months after the 13vPCV dose, and at least 5 years after the previous 23vPPV dose, whichever is later.

For Aboriginal and Torres Strait Islander adults aged ≥50 years, these vaccine doses are covered in the routine recommendation and do not need to be repeated.

For non-Indigenous adults aged ≥70 years, a dose of 13vPCV is part of the routine recommendation and does not need to be repeated.

≥18 years

If the person has never received a dose of 13vPCV, give a single dose of 13vPCV, preferably before 23vPPV.

There is a maximum limit of 3 doses of 23vPPV during adulthood (age ≥18 years). Give the 1st adult dose at diagnosis (after 13vPCV — see above) or at least 5 years after the last 23vPPV dose, whichever is later.

Whenever possible, give the 13vPCV dose(s) before the recommended 23vPPV dose(s). If 13vPCV is given after 23vPPV, wait at least 12 months between 13vPCV and the last 23vPPV dose. The recommended minimum interval between a 13vPCV dose and a subsequent 23vPPV dose is 2 months. The recommended minimum interval between any two 23vPPV doses is 5 years.

If asplenia is diagnosed at age ≥65 years (age ≥50 years for Aboriginal or Torres Strait Islander adults), only a single revaccination dose of 23vPPV is recommended.

Older children and adults with asplenia who have never received any 13vPCV dose are recommended to receive a single dose of 13vPCV.80 This should precede 23vPPV doses, when possible. However, if they have already received 1 or more doses of 23vPPV, they should receive 13vPCV at the next available opportunity, and at least 12 months after the last 23vPPV dose. A 2nd dose of 23vPPV is recommended 12 months after the 13vPCV dose, or 5 years after the previous 23vPPV dose, whichever is later. Pneumococcal disease outlines the age-specific recommendations.

People with autoimmune conditions are at higher risk of vaccine-preventable diseases, and associated morbidity and mortality. Examples of these conditions are:

systemic lupus erythematosus

rheumatoid arthritis

inflammatory bowel disease

multiple sclerosis

These people are also at risk of infection as a result of treatment with immunosuppressive agents such as corticosteroids and DMARDs (disease-modifying anti-rheumatic drugs).81 DMARDs encompass a range of anti-inflammatory and immunosuppressing agents. The resulting level and nature of immunocompromise in each person depends on:

the specific agent(s) used

the mechanism of action

the dosage

whether the treatment is combined with other therapies, such as corticosteroids (see People receiving corticosteroid therapy)

People with autoimmune diseases and other chronic conditions are recommended to receive inactivated vaccines to optimise protection against disease. There is potential for reduced immunogenicity of vaccines in these people due to both immunosuppressive treatment and the underlying disease.82-84 Extra vaccine doses, such as for pneumococcal vaccine, may be needed.

However, clinical and laboratory measures of disease activity, and the choice, duration and dose of immunosuppressive therapy, do not always predict who will respond poorly to vaccination.83,85,86

However, certain people on DMARDS may receive live vaccines in consultation with a specialist, and with careful consideration of their immune function and current and future disease risk.87 For example, people on low-dose conventional synthetic DMARDs (csDMARDs) may receive zoster vaccine (see Herpes zoster).

In general, people who are immunocompromised and receiving biological DMARDs (bDMARDs) or targeted synthetic DMARDs (tsDMARDs) should not receive live vaccines until at least 12 months after therapy has ended. However, seek specialist advice about the most appropriate interval for the person and their individual circumstances.

Infants should receive inactivated vaccines according to the recommended schedule. However, immune responses may be suboptimal. These infants may need extra inactivated vaccine doses — seek expert advice from the treating specialist and an immunisation expert.

Association between vaccines and autoimmune conditions, such as Guillain–Barré syndrome

Overall, theoretical concerns that vaccines exacerbate or cause autoimmune diseases such as rheumatoid arthritis, type 1 diabetes and multiple sclerosis have not been substantiated. Large epidemiological studies have not verified these sporadic case reports.91-94

In almost all cases, people with autoimmune disease can safely receive inactivated vaccines.

In 1976, a small increased risk of Guillain–Barré syndrome (GBS) in the 6 weeks after vaccination was associated with a type of influenza vaccine in the United States. Since then, close surveillance has shown that GBS has occurred at a very low rate of up to 1 per 1 million doses of influenza vaccine, if at all.95

People with a history of GBS whose first episode was not after influenza vaccination have an extremely low risk of recurrence of GBS after vaccination.96-98 Influenza vaccination is recommended for these people.

Influenza vaccination is generally not recommended for people with a history of GBS whose first episode occurred within 6 weeks of receiving an influenza vaccine. There is limited data on the risk of recurrence of GBS in people where the first episode occurred within 6 weeks of influenza vaccination (i.e. the first episode was possibly triggered by the vaccine). In these people, discuss the potential for recurrence if vaccinated, the potential for exacerbation following influenza infection, and other protective strategies (e.g. vaccination of household members). Vaccination can be considered in special circumstances, such as when an alternative cause for GBS, such as Campylobacter jejuni infection, was found or the risk of influenza disease is considered high.

Many well-conducted studies have shown no increased risk of GBS after HPV vaccine.99 One smaller study suggested a possible very small increased risk, but this study had a number of limitations.99 There is ongoing research to monitor whether there is any increased risk of GBS after HPV vaccine.

Narcolepsy (sudden sleeping illness) was associated with AS03-adjuvanted pandemic influenza vaccines in 2009–10. This was mainly seen in the Scandinavian population, and affected children especially.100-102 These vaccines were not used, and are not available, in Australia.

Hypopituitarism

Hypopituitarism is not a contraindication to vaccination if the person is only receiving physiological corticosteroid replacement for their condition. This is because physiological doses of corticosteroids are not considered immunosuppressive.

Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children: recommendations from the National Institutes of Health, Centers for Disease Control and Prevention, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. Rockville, MD: AIDSinfo, US Department of Health and Human Services; 2018. https://aidsinfo.nih.gov/

Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Rockville, MD: AIDSinfo, US Department of Health and Human Services; 2018. https://aidsinfo.nih.gov/

Page history

Editorial changes to timing of live vaccine doses in adults and children taking corticosteroids, assessing level of immunocompromise in children and adults with HIV, and vaccination of infants born to mothers who received bDMARDs during pregnancy updated.

More about Immunisation

Using the Handbook

Printed content may be out of date. For up to date information, always refer to the digital version: https://immunisationhandbook.health.gov.au/vaccination-for-special-risk-groups/vaccination-for-people-who-are-immunocompromised.